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6 Accident Incident Report Format

This document outlines an accident/incident investigation report template. The template includes sections to provide details of the incident such as location, description, injuries, damages, root cause analysis, corrective actions, and sign-offs. It is used to document workplace accidents or incidents within 4 days for recordable incidents.

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madhav jade
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125 views2 pages

6 Accident Incident Report Format

This document outlines an accident/incident investigation report template. The template includes sections to provide details of the incident such as location, description, injuries, damages, root cause analysis, corrective actions, and sign-offs. It is used to document workplace accidents or incidents within 4 days for recordable incidents.

Uploaded by

madhav jade
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Accident / Incident Investigation Report

Doc. No. EHS/F/006/00

Project Name: - Date:

Location: -
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Investigation Reports should be initiated within 24 hours of the initial notification. Investigation reports must be
completed within 4 calendar days for recordable incidents.

Accident/incident Category (Tick as applicable)

Fatality Major Minor First Aid Near Miss Dangerous Occurrence Fire
Environmental Hazard

Incident/Accident Information

Incident Start Date: Incident Start Time:

Incident End Date (if applicable): Incident End Time (if applicable):

Location:

Occurrence Description:

Name of Affected Person:

Age: Sex:

Job Title: Employer/contractor:

Address of the Victim:

Date Reported: Time Reported:

Reported to: Job Title:

Witness Names:

Investigation Team Members Name:

Investigation Report Date:

Initial Report □ Final Report □

Injury Detail / Body’s part affected if any/:

Damage description If any:

Environmental release if any:

Description of the Incident:


(Include in chronological order. Attach photos/sketches as appropriate.)

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Accident / Incident Investigation Report

Doc. No. EHS/F/006/00

Root Cause of the Incident:

Corrective /preventive Actions Agreed.


Action(s) Responsible Person Due Date Completion Verification

Key Learning from the incident:

Signature of Contractor:

Signature of Safety In charge:

Signature of Project In charge:

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